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Phase 3a > 3a Obstetrics & Gynaecology > Flashcards

3a Obstetrics & Gynaecology Flashcards

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1
Q

How would you manage menopause? This includes premature ovarian failure.

A

Current or previous breast cancer you do NOT give hormonal treatment
- Can give venlafaxine instead (clonidine, gabapentin)

Premature ovarian failure
- Depending on preferences you can use COCP or HRT until 51 years

With uterus
- You MUST give progestogen (Mirena, cyclical or continous // refer below), if not they are at risk of endometrial hyperplasia and cancer

< 50 years and 2 years of amenorrhoea OR > 50 years with 1 year of amenorrhoea (no need for contraception)
- Continuous progestogen + oestrogen

Mirena use (as it provides continuous progestogen) in all ages
- Continuous oestrogen

< 50 years and < 2 years of amenorrhoea OR > 50 years with < 1 year amenorrhoea (those in this category still require effective contraception)
- Continuous oestrogen + cyclical progestogen to induce withdrawal bleeding (can be every 3m if irregular bleeding)

Others: CBT, vaginal oestrogen + moisturiser (no need to give progestogen)

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2
Q

What are some signs and symptoms of menopause?

A

Vasomotor
- Hot flushes and sweats
- Chills

Emotional
- Mood swings low mood and anxiety
- Decreased libido

Systemic
- Brain fog/memory
- Fatigue and insomnia (think cannot sleep due to sweats/flushes)
- Dry and thinned skin
- Hair loss
- Weight gain
- Muscle/joint aches
- Headaches

GU:
- Dysuria, increased UTIs
- Vaginal dryness and atrophy
- Superficial dyspareunia
- Prolapse

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3
Q

What can cause premature menopause? Are there any complications?

A

Premature menopause is the cessation of menstruation < 40 years of age

Iatrogenic:
- Hysterectomy + bilateral salpingoophrectomy
- Chemoradiotherapy

Idiopathic
Familial
Fragile X syndrome
Turner syndrome

Others: inhibin B mutation, autoimmune disease, enzyme deficiency

Complications:
- Osteoporosis
- CVD
- Alzheimer’s

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4
Q

How does adenomyosis differ from endometriosis? How would you manage adenomyosis?

A

Adenomyosis is when there is endometrial tissue in the myometrium (hence oestrogen dependent, cyclical pain and resolves after menopause)
- Results in menorrhagia, cyclical dysmenorrhoea, infertility and dyspareunia
- Uterus is tender and boggy (softer than fibroids)

Who gets adenomyosis?
- Older multiparous women (vs younger nulliparous women in endometriosis)

Investigations
- TVUSS
- GS is hysterectomy and biopsy

You would manage adenomyosis like you would for menorrhagia:
Desire for fertility
- Mefanemic acid (NSAID - hence use if there is also dysmenorrhoea)
- Tranexamic acid (antifibrinolytic)

Desire for contraception
- Mirena IUS 1st line
- COCP or cyclical POP 2nd line
- Hysterectomy/uterine artery embolisation/endometrial ablation

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5
Q

What is lichen sclerosis? Who gets LS, and how do you treat it? What are some complications of untreated LS?

A

Lichen sclerosis is inflammation of the skin (caused by lymphocytes)

Can present in males and females of any age
- But F>M
- More common in middle aged women

Risk factors
- Autoimmune disease (e.g., coeliac, T1DM, alopecia, hypothyroidism, Addison’s, vitiligo)

Presentation:
- Dry, thin (atrophic), shiny paper-like skin white-patches
- Lichenification and hyperkeratosis
- Itching and soreness
- Can appear red/bleeding with excoriations if scratching

Female:
- Figure 8 appearance
- Superficial dyspareunia due to narrowed interoitus

Male:
- Unretractile or tightly adhered foreskin/prepuce (BXO and phimosis)
- White band around tip of foreskin

Complications:
- Vulval cancer (squamous cell carcinoma)
- Reabsorption of the labia minora
- Fusion of foreskin/phimosis

Diagnosis: biopsy
- Not required to start treatment! Only if unresponsive

Management
- Refer to dermatology
- Potent topical steroids (clobetasol) + emollients

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6
Q

What are some risk factors for developing vulval cancer? How does vulval cancer present?

A

Lichen sclerosis
HPV 16 and 18 infection
Old age

Presentation
- Itching and soreness
- Persistent lump + ulceration
- Dysuria or painful urination
- Hx of recurrent ‘UTI or thrush’
- PMH of HPV, VIN or lichen sclerosis

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7
Q

What is Asherman’s syndrome?

A

Formation of adhesions within the uterine cavity due to previous trauma (TOP, hysteroscopy and biopsy, intrauterine surgery [e.g., removal of fibroids or RPOC])

Presentation
- Asymptomatic is NOT Asherman’s
- Dysmenorrhoea
- Lighter menstrual bleeding
- Infertility or recurrent miscarriage

Investigations
- GS: hysteroscopy
- Hysterosalpingography
- Sonohysterography
- MRI

Management
- Conservative management
- Adhesiolysis during hysteroscopy

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8
Q

When are patients first called for cervical screening? What happens to the samples?

A

25 years (until 65 years)
- Every 3 years from 25-49
- Every 5 years from 50
- Can request 1x after 65 if no screening since age < 50

The samples are first tested for high-risk HPV
- Only if HPV + will they be sent for cytology

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9
Q

What is atrophic vaginitis and its management?

A

Atrophic vaginitis is the thinning, irritation and inflammation of vaginal tissue due to the lack of oestrogen after menopause

Presents with:
- Superficial dyspareunia
- Dryness/itching/soreness
- Loss of libido
- Recurrent UTI
- Prolapse

Management:
- Vaginal moisturises, lubricants and vaginal oestrogen
- DO NOT give vaginal oestrogen if previous breast cancer or oestrogen sensitive cancers

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10
Q

What is PCOS and how will patients present? Which is higher in PCOS: LH or FSH?

A

Pathophysiology
- Low FSH compared to LH means excess androgens are produced in comparison to what is needed to make oestrogen (LH stimulates theca cells to produce androgens which are used by FSH stimulated granulosa cells to make oestrogen; androgens are then converted to testosterone!)
- Hence no progesterone from corpus luteum meaning no/irregular menstruation
- Weight gain = increased fat cells + insulin resistance + oestrogen production

LH is higher than FSH in PCOS
- Normally FSH is meant to be higher

Triad (2/3 required)
- Oligomenorrhoea/amenorrhoea
- Hyperandrogenism (biochemical or clinical)
- Cystic ovaries (ovary > 10mL or > 12 follicles in 1 ovary)

Presentation
- Oligomenorrhoea/amenorrhoea
- Infertility
- Weight gain, fatigue, low mood
- Acne
- Hirsutism and virilization (male-pattern baldness)
- Acanthosis nigricans
- Possible dysmenorrhoea and menorrhagia

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11
Q

What is endometriosis and how would someone present? What is the typical triad? How would you investigate endometriosis?

A

What is endometriosis?
- Endometrial tissue outside of the endometrium BUT not in myometrium (commonly affecting the uterosacral ligament, ovaries, pouch of Douglas, fallopian tube, peritoneum, bladder and bowel but can also affect the lungs!)
- Oestrogen dependent so will resolve with menopause

Typical patient
- Nulliparous young female

Risk factors (high oestrogen)
- Nulliparity
- Early menarche

Triad
- Deep dyspareunia + menorrhagia + cyclical dysmenorrhoea

Other features
- Haematochezia
- Haematuria
- Infertility
- Dyschezia
- Dysuria
- Fatigue, depression
- Constipation
- Chronic pelvic pain (dull/heavy)

Investigation and examination
- Examination: speculum (fixed retroverted uterus + endometrial nodules on posterior wall/fornix) + bimanual (adnexal mass)
- GS: laparoscopy + biopsy (BUT you do not need this to treat)
- TVUSS/TAUSS is NORMAL
- N.B., Ca-125 can be raised

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12
Q

How would you manage endometriosis? What are some complications of endometriosis?

A

Aim of medical management is to reduce oestrogen fluctuation/abolish cycle!

Endometriosis = endometrial tissue

Conservative:
- COCP continuously first line if wanting contraception
- Mefanamic acid first line if wanting fertility
- POP/GnRH analogues - only pre-operation /implant/injection/Mirena IUS

Surgical:
- Ablation/excision of nodules to preserve fertility
- Hysterectomy + bilateral salpingoophrectomy

Complications
- Adhesion formation
- Infertilty
- Ectopic pregnancy
- IBD association

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13
Q

Can you tell me about fibroids?

A

What are fibroids?
- Leiomyomas // smooth muscle tumours
- Types: submucosal, pedunculated, subserosal, intramural
- They are oestrogen dependent and resolve after menopause

Risk factors
- Multiparous
- Older age
- BME
- Early menarche/late menopause/later first pregnancy
- Family history

Presentation
- Can be asymptomatic
- Enlarged uterus/abdominal mass that should be non-tender
- Menorrhagia
- Dysmenorrhea
- Pressure symptoms (frequency, urgency, constipation)
- Abdominal pain and deep dyspareunia

Investigations: TV or TAUSS

Management (like menorrhagia)
- All > 3cm or submucosal then refer to gynaecology
- If < 3cm and wanting contraception = Mirena IUS 1st line (others ref. > 3cm)
- If > 3cm and wanting contraception = cyclical POP/COCP
- Conservative and wanting fertility = tranexamic acid or mefanamic acid
- To improve fertility: myomectomy
- Others: uterine artery embolisation
- Definitive: hysterectomy
- N.B., can give GnRH analogues prior to surgery to shrink the fibroids

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14
Q

What are endometrial polyps?

A

Outgrowths of endometrial tissue
Causes menorrhagia

TVUSS
Hysteroscopy + biopsy/resection

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15
Q

Can you summarise endometrial hyperplasia and its management for me?

A

Presents as post-menopausal bleeding, menorrhagia or intermenstrual bleeding

Risk factors (think unopposed oestrogen or lack of progesterone)
- PCOS
- Oestrogen only HRT
- Granulosa cell tumour
- Obesity (due to aromatase in fat cells = increased oestrogen production)
- Tamoxifen use
- Nulliparity
- Early menarche and late menopause
- HNPCC

Protective factors
- COCP/POP/IUS/implant/injection
- Smoking
- Hysterectomy

Types of hyperplasia
- Simple/complex typical/atypical

Investigations
- TVUSS (> 4mm is abnormal if post-menopausal)
- Hysteroscopy + biopsy

Management (if no atypical features)
- Mirena IUS
- Continuous POP
- Other progesterone contraceptions
- Follow up every 6 months!

Management if atypical
- Hysterectomy
- Mirena if surgery not desired

Complications
- Endometrial cancer

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16
Q

What are some causes of post-coital bleeding?

A

Cervical cancer
Ectropion
Atrophic vaginitis
STI
Vaginal cancer
Polyps

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17
Q

What are some causes of post-menopausal bleeding?

A

Remember 2WW TVUSS if > 55 with PMB

ENDOMETRIAL CANCER UNTIL PROVEN OTHERWISE
Endometrial hyperplasia
Vaginal/vulval cancer
Atrophic vaginitis
STI
Fibroids/polyps
HRT
Ovarian cancer (especially theca cell)
? Has it come from the bowel/bladder

Investigations
- TVUSS 1st line
- Hysteroscopy + biopsy is GOLD STANDARD

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18
Q

What are some causes of inter-menstrual bleeding?

A

Endometrial cancer
Endometrial hyperplasia
Fibroids
Polyps
Cervical cancer
Ectropion
Miscarriage
Ectopic pregnancy
STI
Contraception use (especially first few months of progesterone contraception)
Spotting during ovulation or implantation

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19
Q

What are the risk factors for developing cervical cancer? Are there any protective factors?

A

Persistent HPV infection (16 and 18)

Risk factors:
- Long-acting contraceptive (COCP/POP/IUS/IUD)
- Multiple sexual partners
- Early first intercourse
- No vaccination uptake or non-attendance at screening
- Smoking

Protective:
- HPV vaccine
- Condom use

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20
Q

What are the risk factors for developing endometrial cancer? Are there any protective factors?

A

Risk factors (think unopposed oestrogen or lack of progesterone)
- PCOS
- Oestrogen only HRT
- Granulosa cell tumour
- Obesity (due to aromatase in fat cells = increased oestrogen production)
- Tamoxifen use
- Nulliparity
- Early menarche and late menopause
- HNPCC

Protective factors
- COCP/POP/IUS/implant/injection
- Smoking
- Hysterectomy

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21
Q

Can you tell me about hydatidiform moles?

A

A form of gestational trophoblastic disease

Risk factors: extremes of reproductive age, Asian, previous molar pregnancy

Partial mole: normal ova is fertilised by 2 sperm (or 1 sperm which eventually duplicates)

Complete mole: abnormal ‘empty’ ova is fertilised by 2 sperm

Presentation
- Hyperemesis gravidarum
- Amenorrheoa
- Rapidly enlarging uterus (larger than expected for gestational age)
- Bleeding
- THYROTOXICOSIS (hCG mimics TSH)

Investigations
- TVUSS (snowstorm appearance due to all the theca-luteal cysts)
- Serum beta-hCG
- Uterine evacuation + biopsy/histology of products

Management
- Urgent complete evacuation of uterus +/- anti-D
- +/- chemoradiotherapy
- Monitor beta-hCG levels every 2w until normal
- No longer need to monitor after subsequent pregnancies

Complications
- Malignancy/recurrence
- Choriocarcinoma
- Invasive mole (from complete mole)

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22
Q

What is hyperemesis gravidarum? What is the diagnostic triad?

A

Pathophysiology
- Excessive vomiting causing dehydration and ketosis

Risk factors
- First trimester
- Female foetus
- Molar pregnancy
- Multiple pregnancy
- FHx or previous hyperemesis gravidarum
- Hyperthyroidism
- Smoking is protective

Presentation
- Excessive vomiting
- Triad: > 5% weight loss + dehydration + electrolyte imbalance

Investigations
- USS
- LFT, U&E
- Urine dipstick + MSU

Management
- A to E resuscitation + NBM if necessary
- Anti-emetics: PO promethazine or cyclizine
- 2nd line: prochlorperazine or metoclopramide or ondansetron
== Do not use metoclopramide for longer than 5 days
- Hospital admission for IV fluids + antiemetics + enteral feeding
- Others: ginger, P6 acupuncture/pressure point stimulation
- K+ and B1 replacement
- LMWH
- Steroids (prednisolone, hydrocortisone) last line

Complications
- Wernicke’s encephalopathy
- Hypovolaemic shock, AKI, liver failure
- Metabolic alkalosis
- Mallory-Weiss tear
- Central pontine myelinosis
- Preterm delivery

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23
Q

When would you admit someone with hyperemesis gravidarum to hospital?

A

Electrolyte imbalance
Ketones in urine
> 5% pre-pregnancy weight has been lost
Not tolerating oral intake

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24
Q

What is an ectopic pregnancy? How could it present and how do you manage?

A
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25
What are the symptoms of miscarriage and do we perform any investigations? What is the management of miscarriage?
Miscarriage is the loss of a foetus before 24 weeks of gestation Risk factors - Early pregnancy - Maternal health problems - Abnormal foetus - Weak cervix - Abnormal uterus Presentation - PV bleeding (can be heavy) after a period of amenorrhoea - Abdominal pain Management (+ anti-D if surgical management) - Watchful waiting - PV misoprostol or surgical/vacuum removal of products of conception - Measure beta-hCG // take a pregnancy test after 3 weeks
26
What are the types of miscarriage?
Recurrent miscarriage = 3 or more consecutive miscarriages Threatened miscarriage - Abdominal pain + bleeding but cervical os is closed on examination Inevitable miscarriage - Abdominal pain + bleeding but cervical os is open on examination Complete miscarriage - Abdominal pain + bleeding + closed os and no products visible on USS Incomplete miscarriage - Abdominal pain + bleeding but products visible on USS Missed miscarriage - Dead foetus on USS - ‘Empty sac’ or ‘blighted ovum’
27
How can terminations of pregnancy be performed? What is the timeframe allowed?
Requires 2 practitioners to approve TOP All GA can use medical or surgical TOP < 24 weeks: - Pregnancy carries risk of harm (physical/mental) to mother - Pregnancy carries risk of harm (physical/mental) to other dependants No limit if: - Foetus has significant disability - Pregnancy is life-threatening to mother - Pregnancy will cause grave injury to mother (physically or mentally) What is used? - Anti-D to all >= 10+0 even if medical TOP - PO Mifepristone + PV misoprostol 48 hours apart // if 10+1 onwards, take misoprostol every 3 hours until products are passed - Surgical (suction or dilation + curettage) + MTZ/doxycycline prophylaxis
28
How would you induce labour?
29
What is failure to progress in labour and how do you manage it?
30
What is pelvic inflammatory disease? What is the antibiotic regimen of choice?
31
What is bacterial vaginosis and how does it present?
Bacterial vaginosis = loss of normal vaginal flora due to overgrowth of anaerobes (gardnerella, mycoplasma hominids, mobiluncus, prevotella) It is not an STI! Risk factors: - Sexual activity (semen) - Douching - Use of bubble baths/antiseptics/bath shampoos - BME Presentation - Asymptomatic - Greyish-whiteish foul-smelling (fishy) discharge that is quite watery and thin - NO itching or dyspareunia Examination: - Speculum - Abdominal if necessary Investigations (not necessary to swab for microscopy and staining) - HVS or low self-swab for microscopy (salt and pepper appearance, clue cells) - Narrow range pH paper (> 4.5) - Whiff test + BV diagnostic criteria (Amsel) - Clue cells and low WCC - pH > 5.5 - Whiff test + *smells like fish* - Grey-white discharge
32
Do you treat bacterial vaginosis? Tell me about the different approaches if someone is and is not pregnant.
Offer all self-care advice - Avoid douching - Avoid bath products (shampoos, bubble baths, antiseptics) Non-pregnant: - PO metronidazole 1st line - Intravaginal metronidazole or clindamycin (think clINdamycin goes INside) In pregnancy: *never give STAT metronidazole in pregnancy* - Asymptomatic = consult obstetrics - Symptomatic = PO metronidazole > vaginal metronidazole or clindamycin
33
What are the complications of BV in pregnancy?
Miscarriage or stillbirth PPROM, premature labour, low birthweight baby Endometritis postpartum
34
What is the “baby blues” triad? When does it start and end?
Tearfulness Anxious Irrritable Starts within a few days of birth and resolves by 14 days post-partum
35
How long is Mirena licensed as HRT?
4 years
36
Would you investigate menopause?
Not if >= 45 years If < 45 years then FSH must be raised > 25 IU/L in 2 samples at least 4 weeks apart with > 4 months of amenorrhoea
37
What are some complications of HRT?
38
What is the most common cause of PV discharge in women of child-bearing age?
Bacterial vaginosis
39
What discharge do you see with BV?
Grey-white thin discharge that smells like fish NO itching/dyspareunia
40
How would trichomonas discharge appear?
41
What is trichomonas vaginalis and how will patients present?
42
What are ‘triple swabs’ and what do they test for?
43
What are some non-malignant differentials for breast lumps?
44
What are the different types of breast cancer?
45
What are some presenting symptoms of breast cancer?
46
When would you 2-week wait someone for suspected breast cancer?
47
What are the causes of cyclical dysmenorrhoea?
Adenomyosis Endometriosis Fibroids Polyps Ovarian cysts
48
What are some causes of menorrhagia?
Gynaecological: - Dysfunctional uterine bleeding - Copper coil - PID - Fibroids - Polyps - Endometrial cancer/hyperplasia - Endometriosis - Ademonymosis - PCOS Systemic: - Bleeding disorders and anticoagulant use - Liver/kidney disease - Hypothyroidism
49
How would you manage menorrhagia in a woman wanting fertility?
Tranexamic acid if no associated dysmenorrhoea Mefanamic acid if associated with dysmenorrhoea
50
How would you manage menorrhagia in a woman who does not want fertility?
Manage underlying causes (fibroids, polyps, endometriosis) Management for menorrhagia without other causes - Mirena IUS (licensed for 5 years) // not if fibroid > 3cm or other structural abnormalities of the uterus - COCP - Cyclical POP Specialist management for menorrhagia without other causes: - Uterine artery embolisation - Endometrial ablation (N.B., can be difficult to spot endometrial cancer after ablation!) - Hysterectomy
51
Which contraception can cause menorrhagia?
Copper IUD!
52
How would you investigate and examine menorrhagia?
NO need to examine unless patient wants IUS/IUD FBC TFT U&E and eGFR LFT Coagulation screen Iron studies (ferritin) Swab for STIs TVUSS or hysteroscopy if suspecting a secondary cause of menorrhagia Consider screening for coagulation disorders if menorrhagia since menarche
53
What happens when a sample is HPV +?
Sample is then sent for cytology If cytology reveals no dyskaryosis, recall in 12m (if that is + without dyskaryosis recall in further 12m, if at 24m after first test and still + without dyskaryosis you will send for colposcopy // if - at any re-test then discharge to 3-yearly recall) If dyskaryosis = colposcopy
54
When can you start contraception after pregnancy?
IUD or IUS can be started either within 48 hours or 4 weeks after delivery - If started 4 weeks after delivery then use 7 days of additional protection Progesterone pill, implant or injection can be started anytime - If < 21 days then no additional contraception - > 21 days then additional contraception for 2 days for POP or 7 days for IM/implant COCP can only be started 21 days after (not breasfeeding) or 6 weeks after (breastfeeding) - Use 7 days of additional contraception
55
How would you manage missed COCP?
1 missed pill - Take 2 and no further action if 7 days of good use 2 missed pills, take 2 and: - Week 1 = (emergency contraception) + 7 days of additional contraception - Weeks 2/3 = 7 days of additional contraception and do not miss hormone free interval if in week 3 Window for patch/ring = 48 hours as 1 missed pill
56
How would you manage missed POP?
Missed POP = > 3 hours (or > 12 hours desogestrel) Take missed pill immediately (so take 2) and use additional contraception for 2 days
57
What contraception can you prescribe to older women?
Copper IUD or Mirena IUS POP Implant Stop IM injection and COCP by 50 years
58
How would you investigate PCOS?
Investigations - Basal (d2-5) FSH and LH before typical ‘surges’ in menstrual cycle - LH:FSH (2:1) - Testosterone/androstenedione (raised) - Dehydroepiandrosterone (DHEAS is normal) - Sex hormone binding globulin (low especially in insulin resistance) - Free androgen index (normal or slightly raised) == This is T:SHBG - TSH - GS: TVUSS
59
What are some complications of PCOS?
Endometrial hyperplasia and endometrial cancer due to unopposed oestrogen - NO osteoporosis as oestrogen levels are normal Obstructive sleep apnoea Decreased libido Infertility Weight gain, DM, metabolic syndrome Virilization, hirsutism and male-pattern baldness
60
How would you treat PCOS?
Management - Weight loss to improve fertility - COCP 1st line - Cyclical POP (INDUCE withdrawal bleed) or Mirena IUS - Others: clomifene, facial creams Co-cyprindiol has anti-androgenic activity but has high risk of VTE so can only be used for 3 months!
61
What are some complications of endometriosis?
Infertility Ectopic pregnancy (due to adhesion formation) IBD Increased risk of some ovarian cancer (clear cell and low grade-serous)
62
How do we treat but preserve fertility in endometriosis?
Medical: NSAIDs or paracetamol Surgical: endometrioma ablation/excision
63
What is the endometriosis triad?
Cyclical dysmenorrhoea Deep dyspareunia Menorrhagia
64
What are some complications of fibroids?
Complications - Breech presentation at birth - Premature labour - Obstructed labour - Menorrhagia causing iron deficiency anaemia - Infertility and recurrent miscarriage - Strangulation (pedunculated!) - Red degeneration during pregnancy
65
Can you use the progestogen implant or injection for menorrhagia?
NO - only Mirena IUS or cyclical POP
66
What is red degeneration?
Rapidly growing fibroid outgrows its blood supply = ischaemia > infarction > necrosis Severe abdominal pain + low grade fever in a pregnant woman with known fibroids + vomiting + tachycardia Managed with rest, fluids and analgesia = do NOT surgically remove
67
How would endometrial cancer present?
Post-menopausal bleeding Inter-menstrual bleeding Menorrhagia Irregular bleeding Prognosis is normally very good!
68
What would you see on bloods for endometrial cancer?
Raised platelets Raised glucose Anaemia
69
How would you investigate and manage endometrial cancer?
TVUSS + hysteroscopy and biopsy Treat with TAH + BSO + lymphadenectomy in early stage disease Stage 2-4: chemoradiotherapy If unfit for surgery give progesterone!
70
Which genetic condition is associated with endometrial cancer?
HNPCC
71
What type of cancer is endometrial cancer?
Adenocarcinoma
72
What COCP regimen is used in endometriosis?
Continuous COCP
73
What is cervical cancer and how would it present? How do we investigate and manage cervical cancer?
Cervical cancer is most commonly squamous cell cancer (90%), the rest are adenocarcinoma - Very locally invasive HPV makes protein E6 (inhibits p53) and E7 (inhibits pR6) Presentation - PCB - IMB/PMB - Abnormal appearance on speculum examination (ulceration, bleeding, tumour) - PV discharge, dyspareunia, pelvic pain, weight loss Investigations - Colposcopy + biopsy (acetic acid and Schiller’s iodine // abnormal cells stain white and do not take up iodine) - Swabs to exclude infection - MRI/CT to stage - Examination under anaesthetic to stage Staging - 1: cervix only - 2: cervix and upper 2/3 of vagina - 3: cervix and lower 1/3 of vagina and/or pelvic side wall - 4: beyond pelvis or bladder/bowel mucosa Management - 1a: cone biopsy - 1b: radical trachelectomy - Radical hysterectomy + removal of lymph nodes + chemoradiotherapy - Chemoradiotherapy +/- palliative surgery
74
What is thrush? What are the risk factors, how would it present, and how do we manage? How does it affect pregnancy?
75
What is trichomonas vaginalis? How does it present and how do we manage? Are there any complications in pregnancy?
76
What can you tell me about chlamydia? Does it cause any problems in pregnancy?
77
What is gonorrhoea? How does it present and how does it affect pregnancy?
78
Can you summarise syphilis for me? How would you treat it, and what happens if you get syphilis while pregnant?
79
Can you summarise genital warts in 5 points?
80
Can you tell me about herpes? What do we do if someone has a herpes infection during pregnancy?
81
What is HIV? How would patients present, what can we do to investigate and manage HIV? Are there any special considerations for pregnancy?
82
How would you manage hepatitis B in pregnancy?
83
What happens if you come into contact with VZV while pregnant?
84
What can you tell me about HTN in pregnancy and gestational HTN? How would we manage?
BP >= 140/90 mmHg without signs of end-organ damage (e.g., proteinuria) - Essential hypertension: diagnosis antenatally until 19+6 weeks of pregnancy - Gestational hypertension: diagnosis from 20+0 weeks Management (if BP >= 160/100 admit to hospital + refer urgently to obstetrics) - ACE-i, ARBs and thiazide-like diuretics are contraindicated in pregnancy - Prophylaxis (if not yet diagnosed) : 75-150mg aspirin from 12 weeks - First line: labetalol (CI asthma, give nifedipine) - Second line: nifedipine - Third line: methyldopa (must stop within 48 hours of delivery) - Aim to deliver from 37+0 and offer MgSO4 if indicated - Post-partum: enalapril > nifedipine/amlodipine (Afro-Caribbean then this is 1st line) > labetalol/atenolol
85
What can you tell me about pre-eclampsia and eclampsia? What are the risk factors, investigations and prophylaxis?
Pathophysiolgy - Poor placental perfusion due to poor trophoblastic invasion > spiral arteries are not converted to vascular sinuses (high resistance in spiral arteries) - Means that there is placental ischaemia causing release of renin = vasoconstriction, poor renal perfusion and hypertension Triad: HTN + oedema + proteinuria Major risk factors - Previous pre-eclampsia/GHTN - CKD - HTN - SLE, antiphospholipid syndrome - DM Moderate risk factors - Nulliparity - FHx 1st degree relative with pre-eclampsia - > 10 years from last pregnancy - > 40 years - Multiple pregnancy - BMI > 35 Prophylaxis - 75mg aspirin from 12+0 weeks if 1 major or 2 moderate risk factors Investigations - Urine dipstick (+ = re-dip in 1 week, ++ = urgent referral to obstetrics) - P:Cr - BP - FBC - LFTs - U&E - LDH - PIGF (placental growth factor; low) - PAPP-A (low) - Uterine artery Doppler
86
What is a GU prolapse? Are there any risk factors? How would we manage a prolapse?
Pathophysiology - Herniation of bladder, bowel or cervix into the vagina - Rectocele = rectum - Enterocele = bowel - Cystocele = bladder Risk factors - Multiparity especially multiple vaginal delivery, macrosomic baby or instrumental delivery - Hysterectomy (especially for vaginal vault prolapse) - Post-menopausal // older age - Obesity - Chronic cough (COPD) - Constipation (constant straining) Presentation - Lump or ‘dragging’ sensation down below - Can be constipated and need to digitally reduce the prolapse to defecate - Can have urinary retention, frequency or urgency or symptoms of incomplete emptying - Incontinence - Sexual dysfunction (dyspareunia) - Can be ulcerated if prolapse is below interoitus Investigations - Speculum (Simms) examination - Bimanual examination Management - Weight loss - Pelvic floor exercises/vaginal cone - Vaginal oestrogen - HRT - Pessaries (ring/shelf/gellhorn) // not very useful if posterior wall prolapse - Surgical repair
87
How would we manage pre-existing diabetes in pregnancy?
Change all medications to metformin and/or short-acting insulin only + 5mg folic acid supplementation Deliver by 37-38+6 Aim to normalise HbA1c (< 48 mmol/mol) before conception Monitor for retinopathy and nepropathy Give ketone monitoring strips if T1DM Detailed foetal scan at 20 weeks (Ebstein’s, Tetralogy, hypoplastic left heart)
88
What advice would you provide about folate supplementation in pregnancy?
Take pre-conception and for 1st 12 weeks - 0.4mg or 400mcg is normal dose Take 5mg if - Previous NTD, FHx NTD - Taking antiepileptics - Coeliac disease or thalassaemia trait - BMI > 30
89
What medications must be avoided in breastfeeding?
Lithium Clozapine Aspirin BDZs Carbimazole MTX Sulfonylureas Amiodarone Cytotoxic drugs Ciprofloxacin, tetracycline and chloramphenicol
90
Can you use antiepileptics while breastfeeding?
YES! All are safe :)
91
What is the test used for detecting ovulation?
Progesterone levels taken in the mid-luteal phase (e.g., day 21 of a 28 day cycle)
92
How do you manage post-partum thyroiditis?
Propranolol only - Anti-thyroids have no role as thyroid is not overactive
93
How long would you wait after birth to perform a cervical smear if one is due?
3 months/12 weeks
94
What is the most common cause of PPH?
Uterine atony
95
What are the 4 ‘Ts’ involved in PPH? What are some risk factors?
Tone (uterine atony) Trauma (tear in vaginal wall, rectum, perineum, instrumental delivery, etc.) Thrombin (coagulation disorder) Tissue (retained products of conception) Risk factors? - Polyhydramnios - Previous PPH - Coagulation disorder - Macrosomic baby - Prolonged labour - Pre-eclampsia - Placenta praevia or accreta
96
What is a PPH? How would you classify a PPH?
Definitions - Blood loss > 500mL after delivery of foetus - Major loss > 1000mL - Massive loss > 2000mL - Secondary PPH occurs > 24 hours to 12 weeks after delivery and is commonly caused by endometritis Endometritis: IV gentamicin + clindamycin - Fever, foul smelling lochia, PV discharge and abdominal pain
97
How do we manage a PPH? - Mechanical - Pharmacological - Surgical
Immediate management - Call for senior help - A to E resuscitation is the aim = cannulate with large-bore cannulas + keep warm + catheterise (helps uterus contract) - Take: bloods for FBC, clotting, group + save and CROSSMATCH at least 4 units - Give: IV crystalloids/colloids + O negative blood products if necessary Mechanical - Fundal rub or bimanual compression Pharmacological management - IM oxytocin + tranexamic acid - Misoprostol or carboprost - IV/IM ergometrine Surgical - 1st line: balloon tamponade (intra-uterine Bakri catheter) - B-Lynch suture, litigation of uterine or internal iliac arteries - Hysterectomy
98
What are the cut-off levels for diagnosing anaemia in pregnancy? When do we check for anaemia?
T1: < 110 g/L T2/3: < 105 g/L Post-partum: < 100 g/L Any lower = prescribe oral iron and continue for rest of pregnancy When do you check for anaemia? - Booking - 28 weeks
99
How long before surgery must you stop the COCP?
4 weeks Restart 2 weeks after surgery
100
What is gestational diabetes? Do we screen? Are there any risk factors?
Gestational diabetes is the development of diabetes after 20 weeks of gestation OGTT is investigation of choice - >= 5.6 mmol/L fasting - >= 7.8 mmol/L 2 hours after Screening - Regular urine dipstick at each antenatal appointment - If previous GDM: OGTT at booking and repeat at 24-28 weeks if negative the first time - OGTT if 2x 1+ or 1x 2+ on dipstick or symptoms suggest diabetes OGTT at 14-28 weeks if presence of risk factors - Previous GDM - Previous macrosomic baby (4.5kg or more) - Diabetes in any first degree relative - BMI > 30 - BME ethnicity
101
How do we manage gestational diabetes?
All get referral to antenatal diabetes clinic If fasting glucose < 7.0 mmol/L offer lifestyle advice and follow up in 2 weeks - If no improvement, either start metformin - If no improvement after further 2 weeks = add short-acting insulin If fasting glucose >= 7.0 mmol/L give short-acting insulin +/- metformin Deliver by 40+0 to avoid macrosomia and shoulder dystocia
102
What are the glucose targets for DM in pregnancy?
Fasting <= 5.3 mmol/L 1hr after food <= 7.8 mmol/L 2hr after food <= 6.4 mmol/L
103
What is an absolute contraindication to all hormonal contraceptives?
Current breast cancer
104
How long after TOP can pregnancy tests remain positive?
4 weeks
105
When do we give anti-D prophylaxis in a normal, low-risk pregnancy if the mother is Rhesus -?
28 weeks and 34 weeks 500 IU IM
106
What events require anti-D prophylaxis in a Rhesus - mother?
Any TOP from 10+0 Surgical management of ectopic pregnancy Miscarriage > 12 weeks ECV APH Amniocentesis, CVS or foetal blood sampling Abdominal trauma Bleeding > 12 weeks Painful, heavy bleeding < 12 weeks Tests in babies born to Rh - mothers: cord bloods for Kleihauer, blood group and direct Coombs
107
How do we manage pre-eclampsia and eclampsia?
Management - Admit urgently if BP >= 160/110 mmHg - 1st line: labetalol - 1st line seizure: MgSO4 (N.B., in OD give calcium gluconate) - 2nd line: nifedipine - 3rd line: methyldopa - 4th line: hydralazine When to deliver? - Onset from 37+0 = deliver within 48 hours - Onset 34-36+6 weeks = surveillance + steroids - Onset <34 weeks = surveillance + steroids + MgSO4 If unstable at any GA = deliver
108
What are the presenting features of pre-eclampsia? What are the complications?
Triad: HTN + oedema + proteinuria Monitor BP every 48 hours Pre-eclampsia is often worse after delivery! IV MgSO4 during delivery either 24 hours after delivery or after last seizure whichever later Presentation - Often asymptomatic - RUQ pain +/- hepatomegaly - Oedema - Frontal headache - Eyesight changes (blurring, spots, lines) - Dizziness - N&V - Oedema - Ankle clonus > 3 beats is BAD - Hyperreflexia Complications - HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) = deliver now - Oligohydramnios (placental failure) - IUGR and stillbirth - Eclampsia - PPROM, premature delivery, low-birthweight - Stroke/haemorrhage - Placental abruption
109
What happens when a smear sample is inadequate?
Up to 3 inadequate samples, each 3 months apart, before you send to colposcopy after the third ‘inadequate’ smear
110
How do we manage CIN 1, 2 and 3?
CIN 1 = LLETZ and follow up in 12 months with HPV screen CIN 2/3 = treat and follow up in 6 months with HPV screen
111
What is PMS? How do you investigate and how do we manage?
PMS =. Distressing physical, psychological and behavioural symptoms in absence of organic disease that occurs during luteal cycle and improves at end of menstruation Premenstrual dysphoric disorder = severe PMS with 5 or more symptoms including mood Presentation - Low mood, anxiety, irritability, mood swings - Bloating and weight gain - Breast tenderness - Suprapubic cramps, GI disturbance - Headaches - Acne - Loss of concentration, confidence Investigation - 2-3 cycle diary (daily record of severity of problems) - GnRH agonists resolve symptoms Management - Lifestyle advice if mild: healthy eating, sleeping, exercise - Continuous COCP - SSRI for luteal phase of the cycle
112
Can you summarise the COCP for me?
COCP acts by release a steady amount of oestrogen and progesterone which Mechanism: inhibits ovulation + thickens mucous + thins endometrium COCP prevents mid-cycle LH surge by giving continuous levels of oestrogen and progesterone therefore acting as - feedback so low LH and FSH and GnRH Contraindications - Migraine with aura - > 50 years - > 35 smoking > 15 a day - Breast cancer - Previous VTE/CVD - BMI > 35 - HTN - Obstetric cholestasis Side effects: - Stroke/HTN/VTE - Raised cholesterol - Migraine with aura - Breakthrough bleeding - Breast cancer/cervical cancer - Nausea How to use? - Start d1-5 no contraception needed - Start d6 onwards use 7d of additional contraception
113
Can you summarise progesterone contraception for me?
Mechanism: thickens cervical mucous + thins endometrium + inhibits (ish) ovulation (mainly desogestrel) Mirena THINS endometrium as main mechanism Side effects - Menstrual disturbance (POP) - Low mood - Weight gain - Nausea - Bloating, breast tenderness, acne - Headache - Persistent ovarian cysts How to use? - POP used continuously (within 3hr window / 12hr if desogestrel) - D1-5 of cycle no contraception needed - D6 onwards = 2 days (POP) or 7 days (IM/implant/IUS) of additional contraception
114
Can you summarise copper IUD for me?
Can be used as emergency contraception too Causes heavy menstrual bleeding and cramping Causes endometrial inflammation preventing implantation, and also acts as a spermicide IUD specific: infection, expulsion, perforation, ectopic pregnancy
115
What can you tell me about emergency contraception?
Copper IUD is the most effective - Can be inserted up to 5 days post UPSI or 5 days after ovulation, whichever is latest Levonelle (levonorgestrel) - 72 hour window post UPSI - Inhibits ovulation - Double dose if BMI > 26 or > 70kg - Less effective than ulipristal acetate EllaOne (ulipristal acetate) - 120 hour window post UPSI - Inhibits ovulation, progesterone receptor modulator - Do not give in asthmatics - Cannot use more than once in a cycle - Ulipristal acetate cannot be used alongside other progestagen
116
What is PID? What are the common organisms, risk factors and presentation? How would you investigate and treat?
PID - Infection of the upper genital tract PID organisms - Gonorrhoea - Chlamydia - Mycoplasma genitalium Risk factors - BV - Previous gonorrhoea or chlamydia or STI - < 25 - IUD - Surgical TOP Presentation - Cervical excitation/inflammed cervix - Vaginal discharge - IMB/PCB - Chronic pelvic pain - Deep dyspareunia - Fitz-Hugh Curtis syndrome: RUQ pain - Dysuria - Dysmenorrhoea (secondary) - +/- fever Investigations - NAAT (gonorrhoea, mycoplasma and chlamydia) - HVS (BV, candidiasis, trichomoniasis) - Pregnancy test - Syphilis + HIV bloods - Dipstick - FBC - CRP - GS: laparoscopy Management (McD) - PO metronidazole 14 days + - IM ceftriaxone STAT + - PO doxycycline 14 days Complications - Ectopic pregnancy - Fitz-Hugh Curtis syndrome - Tubo-ovarian abscess - Infertility
117
What is the most common congenital heart disease caused by rubella?
Pulmonary artery stenosis and patent ductus arteriosus
118
How would you treat candidiasis in a pregnant and non-pregnant woman? Does it affect pregnancy? What is classed as ‘recurrent candidiasis’?
Recurrent = 4 or more a year No, does not affect pregnancy Non-pregnant: PO fluconazole or intravaginal clotrimazole pessary Pregnant: intravaginal pessary only (NEVER give ___azole PO) If pessary can also give topical cream
119
How would you treat trichomoniasis?
Metronidazole STAT if non-pregnant Metronidazole 400mg BD 5-7 days if pregnant Non-pregnant can also have tinidazole
120
What are some features of disseminated gonococcal infection?
Triad: migratory polyarthralgia + pustular dermatitis on extremities + tenosynovitis Others: fever
121
How long must someone abstain from intercourse if diagnosed with gonorrhoea infection?
7 days
122
How would you treat chlamydia?
Doxycycline if non-pregnant Erythromycin if pregnant
123
What are some complications of gonorrhoea and chlamydia?
PID Neonatal conjunctivitis PPROM Reiter syndrome (circinate balanitis + arthritis + conjunctivitis) Gonorrhoea: - Disseminated gonococcal infection
124
What medications do you avoid in pregnancy?
Trimethoprim Methotrexate ACE-i/ARB Statins Oral hypoglycaemics apart from metformin Valproate Warfarin DOAC
125
How does placenta praevia present in labour? If not ‘bleeding acutely’
High presenting part Malposition/malpresentation
126
What is failure to progress in labour? Can you give me values for each stage?
First stage: Second stage: Third stage:
127
How do you manage VTE in pregnancy? Is there anything you can give as prophylaxis?
DVT - Doppler USS to diagnostic - Can measure circumference of calf 10cm below tibial tuberosity and if > 3cm difference = DVT - Give LMWH until 6 weeks post-partum or 3 months total (whichever longest) - If unsure of diagnosis, stop treatment and rescan on days 3 and 7 PE: - If confirmed DVT on USS, no need to CTPA or VQ scan - Give LMWH until 6 weeks post-partum or 3 months total (whichever longest) - If unsure of diagnosis, do not stop treatment - Alteplase or thrombectomy if severe Prophylaxis - T1 if 3 risk factors - T3 if 4 or more risk factors - LMWH is prophylaxis and give unlit 6 weeks post-partum as risk is highest after delivery

Phase 3a (4 decks)

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